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Jan.26.2010 04:17 PM PAGE. 2/ 3 <br /> UNAVIED PR0 (;jtAM COMS(HADATFD FORM <br /> UNDER(;RGUND STORAGETILNK <br /> CE krRUCATION OF INSTALLATION /MODIFICATION <br /> (Orw:fi-wol <br /> 1. FACILITYINFORMATION <br /> LiFACTUTY 11)# lgerrcy Uso Only <br /> UUS,UNCSSNAME r.v-rAh'\'NA�!F 1311A.WiV <br /> ,Y .. ................ <br /> !01 <br /> HUSINESS ]L( IA'U <br /> AD ;SS <br /> 11F;01,PtZ(?JFC.`r((Twt*till that AtIl)LY) <br /> 1. 1 ANK INSTALLAWN OR RE'Pl.ACFMFNT CNEfinbor of-Dilm): <br /> 2.PW)NO INS I'ALLATION 0R.R.13PLACEML-VT <br /> OR RE"I'LACEMENT <br /> 4.I JNI-)I::r4 111'S,PENSER CON rAINACNTINSTALLA 110N OR REM-AC)-'W-.N'l* <br /> Cal-mA <br /> D F S CI Z 11)T 10 N OF'WORK BEING�C"Zkll I—fl L F) <br /> UA QVjoe-p-�l "'Wa,"a r—t-q4- <br /> A <br /> * <br /> D+ iF tu <br /> [If. CONITRACT OR INFORMATION <br /> NAIMLO);CONIRACIUR WOO PERFORMIRD iNSTAIIATION i MOMFICATION <br /> L -2—7 <br /> CONTRACTOIt LIC 11 WC CIA I IFICATION Y <br /> 43 (i - <br /> .......... <br /> IV.(14CHFIC'ATION' <br /> 9 Certify that the imilim-mation provided herein is true,necuraW,m9d OW the f0flowing conditions have beem safisfflod: <br /> 0 The in%taller has mat the rquirements.skA liorlb in 73 §?7,J,5_,, in <br /> jibclivisit)m(o)- d(h). <br /> * The underground storage tuns:. Rn)' Prinifiry piping, 'Itid arly semnclary containment was histallud according to <br /> WILIFARry GWISLMSUS Stall&rdS sand any written insuillafion Instruction". <br /> * Al)work listed in the ulanufacturer's inqa[lation checklist has been completed, <br /> * The installation has been inspected and apptove(j by t�te local agency,or if reqUh-4-Y3 by the 10M11 -(1;41lCy, iT1SPCCtCd Vrid(Y.'s-6-fil(d <br /> by a regiistere-d I)rofessional LTELncer htn cducidion 9nd t x ericrice With tutdufgrptlnd storaLte-tank,,.ystem . ...... <br /> NK OWNER OR OWNER'S AGENT DATE' xa. PHOW <br /> (Juh t) TU:�: <br /> NAME(WCERI" R'S FMPLOYER(DBA) 7ke C `NPl'.4*-CS 4Z':(A11ONSTIFITO TANK OVAIH'iR <br /> ❑ LTANKOWNIJ:'k U ?. TANK(x5HMTOP <br /> CONTIZACTOR i,vlml,!:Yl),owm:lz <br />